The Ireland East Cancer Academic Directorate (CaCAD) supported the UCD-GOG team involving clinicians and interdisciplinary team members from the Mater Misercordiae Hospital, St Vincent’s University Hospital and the National Maternity Hospital to embrace ‘Lean methodologies and A3 Thinking’ to redesign and standardise pathways and improve patient experience across their speciality.
The Lean improvement Journey supported by the IEHG Service Improvement Team (SIT) commenced in July 2018 with a Value Stream Analysis (VSA), mapping out the entire service across the institutions within IEHG from initial referral through to end of treatment and survivorship. The VSA allowed the team to agree a ‘Future State’ for the Gynaecological Oncological Service with consensus regarding specific areas of focus for improvement, to optimise both the patient journey and quality of care, ultimately improving patient outcomes and to enable ESGO accreditation.
Following on from the VSA a sequence of Rapid Improvement Events (RIE’s) were undertaken with targeted areas identified for improvement including, triage, MDT, outpatient clinics, survivorship and data availability.
The introduction of a weekly Consultant delivered Triage clinic, has reduced rework and re-discussion at MDT, with all complete referrals triaged <7 days of receipt. The number of patients re-discussed at MDT has reduced from 10% to 2%. The reduction in overall discussions has had a positive impact on weekly MDT, as it is less time constrained with re-referrals resulting in minimal overruns. A joint, cross institution MDT meeting was introduced and occurs monthly.
The team introduced a standardised electronic referral form and a comprehensive patient document that follows the patient and is updated at each contact point from triage, to MDT and development of treatment plan. This is emailed to the referring institution/GP, thus assisting the seamless flow of information throughout the patient journey.
Patient participation and involvement allowed patients the opportunity to voice their priorities for service delivery. ‘Reduced clinic waiting and increased time with MDT team members at clinic’ were highlighted as fundamental changes required for the service. A ‘Priority Clinic’ for all new cancer diagnosis and recurrence patients was established. A staggered appointment system was introduced to minimise clinic wait times with an increase to Clinician patient assessment time from 20mins to 45mins. Patients assessed at Priority Clinic have same day discussion at MDT with an agreed treatment plan < 28 days from initial referral (100% of patients V 72% pre improvement work). All patients have treatment commenced < 62 days from initial referral (100% of patients V 66% pre improvement work).
A Review clinic was introduced also utilising a staggered appointment system and Clinician/patient assessment time has increased from an average 10 mins to 30mins for review patients since change in clinic structure. The introduction of virtual clinics has reduced unnecessary hospital visits for patients.
The VSA identified the need to develop and define a survivorship programme within the Gynae Oncological Service. A Holistic Needs Assessment was undertaken to understand demand for supplementary survivorship services, and to assist in developing a survivorship treatment plan for all patients in line with the NCCP survivorship strategy. The team are working towards developing a local and national directory of services available, and a Nurse Led Survivorship clinic.
As part of the improvement work a Data Set and Data Dictionary was defined and agreed, with a reduction in data points collected from initial 1,500 to 150. This assists in avoiding ambiguity of data extraction reporting and analysis. A dashboard was developed to track and report clinical data for each cancer type inclusive of data extraction points for ESGO accreditation as an Ovarian Cancer Surgical Centre which was received in October 2020.
